Service Lines: Working Toward a Value-Based Future.

SUMMARY: The primary drivers for service line development have historically been market differentiation and profitable growth. In the current transition to value-based care, however, several other factors are now driving service line strategy. Specifically, in a value-based world, service lines must be patient centric, not provider centric; they must focus on more than hospitals; and they must be market facing.To build the operating model of the future and succeed in a value-based world, health systems need to reimagine the clinical, operational, and financial features of today's service lines. In working toward this future state, a coordinated, evidence-based care model with a multidisciplinary care team must replace today's episodic care. Easy access to prompt solutions and a seamless, low-stress experience for both patients and providers will be new competitive differentiators, along with cost transparency. Outcomes, patient convenience, and the total cost of care will drive future service line relationships between health systems and physicians. The criteria for selecting physician partners will be materially different, too.In implementing this future-state model, healthcare organizations will need to reconcile several opposing forces and tear down structural and operational silos. Health systems that can navigate through these challenges can realize numerous benefits.

Physician Versus Nonphysician Instruction: Evaluating an Expert Curriculum-Competent Facilitator Model for Simulation-Based Central Venous Catheter Training.

INTRODUCTION: Healthcare simulation supports educational opportunities while maintaining patient safety. To reduce costs and increase the availability of training, a randomized controlled study evaluated central venous catheter (CVC) insertion training in the simulation laboratory with nonphysician competent facilitators (NPCFs) as instructors. METHOD: A group of learners naive to central line placement participated in a blended curriculum consisting of interactive online materials and simulation-based training. Learners were randomized to training with NPCFs or attending physician faculty. The primary outcome was simulated CVC insertion task performance, graded with a validated checklist by blinded physician reviewers. Learner knowledge and satisfaction were also evaluated. Analysis was conducted using noninferiority testing. RESULTS: Eighty-five students, 11 attending physicians, and 7 NPCFs voluntarily participated. Noninferiority testing of the difference in CVC insertion performance between NPCF-trained learners versus physician-trained learners found no significant difference [rejecting the null hypothesis of inferiority using an 8% noninferiority margin (P < 0.01)]. In addition, there was no difference found between the 2 groups on pre/post knowledge scores, self-reported learner comfort, course satisfaction, or instructor satisfaction. CONCLUSIONS: An introductory CVC curriculum can be taught to novice learners by carefully trained and supported NPCFs and achieve skill and knowledge outcomes similar to learners taught by physicians.

Virtual Electronic Health Record Technology with Simulation-Based Learning in an Acute Care Pharmacotherapy Course.

Electronic health record (EHR) technology use in the educational setting to advance pharmacy practice skills with patient simulation has not been described previously in the literature. Therefore, the purpose of this study was to evaluate the impact of a virtual EHR on learning efficiency, perceptions of clinical skills, communication, and satisfaction. This was a prospective study conducted in a cardiovascular therapeutics course in the Doctor of Pharmacy curriculum. Students were randomized to use of a virtual EHR with patient simulation or to patient simulation alone (control). The efficiency of learning was assessed by the time to optimal recommendation for each scenario. Surveys (n = 12 questions) were administered electronically to evaluate perceptions of clinical skills, communication, and learning satisfaction. Data were analyzed with the Mann⁻Whitney U or Wilcoxon signed-rank test as appropriate. Use of the virtual EHR decreased the amount of time needed to provide the optimal treatment recommendations by 25% compared to control. The virtual EHR also significantly improved students' perceptions of their clinical skills, communication, and satisfaction compared to control. The virtual EHR demonstrated value in learning efficiency while providing students with an engaging means of practicing essential pharmacist functions in a simulated setting.

Blended Simulation Progress Testing for Assessment of Practice Readiness.

Objective. To design an assessment of practice readiness using blended-simulation progress testing. Design. A five-station, blended simulation assessment was developed to evaluate patient care outcomes in first- and third-year pharmacy (P1 and P3) students, as well as first-year postgraduate (PGY1) pharmacy residents. This assessment of practice readiness included knowledge and performance evaluations administered as a progress test. Assessment. Eighteen PGY1 residents, 108 P3 students, and 106 P1 students completed the assessment. P3 students scored significantly higher than P1 students across all evaluations. Third-year pharmacy students scored significantly lower than PGY1 residents in interprofessional communications and attitudes of ownership in a standardized colleague/mannequin model station, and in patient communication in a standardized patient station. Conclusion. Learners demonstrated evolving skills as they progressed through the curriculum. A blended simulation integrated progress test provides data for improvement of individual student clinical skills, informs curricular advancement, and aligns curricular content, process, and outcomes with accreditation standards.

Experience With a New Process - Condition T - for Uncontrolled Donation After Circulatory Determination of Death in a University Emergency Department.

BACKGROUND: In the United States, organ donation after circulatory death (DCD) determination is increasing among those who are removed from life-sustaining therapy but is rare when death is unexpected. We created a program for uncontrolled DCD (uDCD). METHODS: A comprehensive program was created to train personnel to identify and respond quickly to potential donors after unexpected death. The process termed Condition T was implemented in the emergency department (ED) of 2 academic medical centers. All ED deaths were screened for uDCD potential. Eligible donors included patients with preexisting donor designation who received cardiopulmonary resuscitation, failed to respond, and were pronounced dead. RESULTS: Over 350 nurses, physicians, perfusionists, organ procurement personnel, and administrators were trained. From February 2009 to June 2010, a total of 18 patients were potential Condition T candidates. Six Condition T responses were triggered. Three donors underwent cannulation, and 4 organs were recovered (3 kidney and 1 liver) from 2 donors. Time from Condition T trigger to perfusion with organ preservation solution ranged from 14 to 22.3 minutes. Perfusion duration was 197 and 221 minutes. No recovered organs were transplanted because biopsies showed prolonged warm ischemia. CONCLUSIONS: It is feasible to create a process to rapidly intervene in the ED for uDCD. However, no organ transplants resulted. The utility and sustainability of an uDCD program in this particular setting are questionable.

Simulation: a teaching tool for liver transplantation anesthesiology.

Anesthesia for liver transplantation (ALT) requires extensive preparation and rapid recognition of changing clinical conditions. Owing to the proliferation of transplant centers, greater number of anesthesia providers need training in specific skills required to treat these patients. These cases are no longer limited to few transplant centers; therefore, reduction of cases in individual centers has created a need for simulation training to prepare and supplement clinical experience. We have developed an ALT simulation course for senior anesthesia residents which combines didactic sessions with live-patient-based and mannequin-based simulation. Outcomes have been measured using pre- and post-simulation course quizzes as well as a survey given at the end of the month-long ALT rotation. Twenty-four senior anesthesiology residents (n = 24) have completed the ALT simulation course. Residents had an average score of 75% ± 10% on the pre-simulation quiz, which increased to 92% ± 6.5% on the post-simulation quiz (p < 0.001). Furthermore, survey scores indicated that residents noted that the course provided an improvement in their preparedness, confidence, anticipation, and understanding of the importance of communication skills in the care of this patient population. The ALT simulation course provided a standardized in-depth exposure to clinical issues involved in the perioperative care of liver transplant patients.

Willingness to perform mouth-to-mouth ventilation by health care providers: a survey.

BACKGROUND: During cardiopulmonary resuscitation (CPR), mouth-to-mouth ventilation (MTM) is only effective if rescuers are willing to perform it. METHODS: To assess the degree of willingness or reluctance in performing MTM, a survey including 17 hypothetical scenarios was created. In each scenario health hazards for the rescuer needed to be balanced against the patient's need for MTM. Respondents were recruited from health care workers attending courses at a medical simulation center. Respondents reported their willingness or reluctance to perform MTM for each scenario using a 4 point scale. RESULTS: The questionnaire had responses by 560 health care workers. Reluctance to perform MTM varied with the scenario. Some health care workers refused to ventilate patients who could benefit from MTM. In all scenarios even when resuscitation was both futile and potentially hazardous, some health care workers were willing to perform MTM. Age and level of experience tend to reduce the propensity to engage in MTM. Parental propensity to ventilate one's own child was stronger than any other motivator. CONCLUSIONS: HIV infection is not the only condition for which rescuers hesitate to perform MTM. Bag-valve-mask devices for mechanical ventilation should be available in all locations where health care workers may be called upon to resuscitate apneic patients making the decision to perform MTM moot.

Utilizing simulation technology for competency skills assessment and a comparison of traditional methods of training to simulation-based training.

BACKGROUND: The respiratory care department of one campus within our health system evaluated simulation-based medical education for training and competency evaluation of the mini bronchoalveolar lavage (mini-BAL) procedure, with an emphasis on patient safety and procedure performance standards. METHODS: Training and competency evaluation occurred in 4 phases. In phase one, 24 staff respiratory therapists (RTs) were randomly chosen and individually underwent a simulation-based test of their mini-BAL performance, using a patient-simulator mannequin. Their performance on this test reflected the effectiveness of traditional training methods. In phase two, 83 staff RTs were given unlimited access to a Web-based curriculum on mini-BAL, including a video of a mini-BAL. They then took 2 tests: one online Web-based test, then a patient-simulator test. In phase three, the same 83 RTs attended a workshop that used the patient simulator for training and practice, then were re-evaluated with the patient-simulator test. Phase four was another simulator-based re-evaluation, 90 days after phase three, to study skills retention. RESULTS: The mean scores were: phase one 73 +/- 10%, phase two 77 +/- 11%, phase three 95 +/- 5% (p < 0.01), phase four 92 +/- 8%. CONCLUSION: Our results suggest that employing simulation technology within a comprehensive departmental program can enhance staff training.

An examination of the value of the generation effect for learning new material.

The generation effect involves an improvement in memory when learners must complete or modify materials. Several researchers have suggested that this effect involves enhanced access to learners' existing memory representations; therefore, the effect should be less effective with meaningless, low meaningful, or unfamiliar material. In the present study, the authors conducted 4 experiments in which legal nonwords were used, and they found no generation effect. In another 2 experiments in which familiar clichés were contrasted with new sentences and with unfamiliar sentences from textbooks, the results showed a greatly reduced generation effect for the new, unfamiliar material. Those findings suggest that memory strategies that depend on the generation effect will have limited effectiveness when they are applied to new or unfamiliar material.